Tisch
1. Guiding ideology Under the leadership of the General Branch and the Hospital Office, we should conscientiously study and implement the spirit of the 20 1x National Conference on Nursing Work, follow the people-oriented Scientific Outlook on Development and the patient-centered service concept, take consolidating basic nursing, improving nursing service, establishing a new industry atmosphere, promoting doctor-patient harmony and improving patient satisfaction as the main content, take ensuring nursing safety as the goal, emphasize process management and link management, and strengthen connotation construction.
Second, the work objectives
1, improve the management system, pay close attention to implementation, and make the nursing work institutionalized, scientific and standardized.
2. Strengthen connotation construction and continuously improve the overall quality of nursing team.
3. Adhere to the people-oriented service concept, conscientiously implement the responsibility system of first inquiry, and continue to carry out the whole process of high-quality seamless service activities to create high-quality service benefits.
Third, the work indicators:
1, qualified rate of basic nursing? 90%, the qualified rate of special and first-class nursing? 90%
2, specialist nursing qualified rate? 90%, technical grade pass rate? 90%
3. What is the qualified rate of nursing document writing? 90%, the intact rate of first aid articles 100%.
4. The qualified rate of disinfection and sterilization is 100%, and the qualified rate of disinfection and isolation is 100%.
5, ward management qualified rate? 95%, and the number of pressure sores per year is 0.
6. Health education patient coverage rate 100%, patient awareness rate? 80%
7. Qualified rate of medical safety management? 90%
8, emergency department, operating room, supply room quality management qualified rate? 90%
9. The number of serious nursing errors and nursing accidents is 0.
10, patient satisfaction rate of nursing service? 98%
1 1, the training rate of nursing staff reached 100%, and the credits or hours of continuing education of nursing staff reached the specified requirements.
12, exchange and publish papers in academic conferences or publications at or above the provincial level every year? 8 articles
13, completion rate of annual work plan? 95%
Fourth, work measures
personnel management
1, in the allocation of nursing staff, as soon as possible to achieve the prescribed proportion of nurses. On the basis of meeting the needs of clinical work and ensuring the quality of nursing work, we should make appropriate adjustments in the hospital as far as possible according to the actual workload under special circumstances, and make plans for the allocation of nursing human resources in emergency situations to avoid the waste of nursing resources.
2, strive to gradually realize the hierarchical use of nurses:
(1) Newcomers and junior nurses should conscientiously complete the nursing work of their classes, the health education guidance for common diseases and the life care for patients, and the nurse in charge should do a good job of guidance;
(2) The nurse in charge and the nurse in charge should also undertake quality control, teaching, lecturing, making nursing plans and scientific research. On the basis of completing the work of this class;
3, the assessment and evaluation of nursing staff at all levels, nursing departments and departments should do a good job in the management of nurses' technical files.
4, strengthen the management of the head nurse, do a good job of inspection and supervision of the head nurse management. Conscientiously implement holistic nursing, change the scheduling mode, and arrange schedules reasonably, scientifically and flexibly, which fully embodies the patient-centered service concept.
(2) Quality management
1. Seriously study the relevant spirit of Shaanxi Provincial Health Department and Chenggu County Health Bureau on the implementation plan of special rectification activities for medical quality management, and carry out special rectification activities for medical quality in combination with the actual situation of the hospital. Continue to carry out hospital management year and medical quality activities, implement the responsibility system of first inquiry, and carry out the whole process of high-quality seamless service activities.
3, the implementation of the nurse night rounds, holiday rounds system. Strengthen the management of key departments, key departments, key links, key people and key time periods.
(3) Safety management
1. Organize to seriously study relevant laws and regulations such as Nurses Regulations, Regulations on Management of Medical Institutions, Regulations on Handling of Medical Accidents, Measures for Management of Hospital Infection, Regulations on Disposable Medical Waste Disposal, etc., and conduct an annual inspection of laws and regulations to improve the legal awareness of nursing staff, care according to law, and protect the legitimate rights and interests of patients and nurses.
2, establish and improve the nursing error reporting and management system, strengthen the management of nursing defects. The nursing department unifies and standardizes the record book of nursing defects and errors, records defects in time, organizes discussions every month, analyzes the reasons and puts forward rectification measures. Record the errors in time and report to the nursing department, and the department will organize discussion, qualitative analysis, cause analysis and corrective measures.
3, pay close attention to the implementation of the core system, strictly implement the rules and regulations and nursing routines and norms. The nursing department formulates the special inspection content of nursing safety, and managers at all levels supervise it regularly and irregularly to find hidden dangers, determine measures and promote improvement.
4. Strengthen communication with patients, hold a work recess once a month, solicit opinions from patients, and solve problems for patients in time. Conscientiously fulfill the obligation to inform of injury treatment or special examination.
5, continue to carry out medical safety month activities, find out their own and work safety hazards, and write a self-examination and self-correction report and submit it to the nursing department.
(4) Business management
1, further deepen the concept of holistic nursing, take patients' needs as service orientation, pay attention to personalized service, further standardize the health education system and process, and ensure the effectiveness of measures.
2. Establish and improve the system of nursing consultation, nursing rounds and nursing case discussion for critical and difficult cases, and strengthen the effect of business rounds. The nursing department organizes the whole hospital nursing rounds every quarter 1 time, and the department organizes the nursing rounds every month 1 time.
3, guide the nursing staff to actively carry out nursing research, to carry out new technologies and new business, from
Write nursing papers and encourage active submission. Those with the title of nurse or above are required to complete at least 1 paper every year.
4. Carry out characteristic nursing of traditional Chinese medicine, popularize appropriate technology of traditional Chinese medicine, and create characteristic Chinese medicine hospital.
5, on-the-job training
(1) Send 2 ~ 3 head nurses to the superior hospital to study new technology (PICC) and new business. Each department sent young nurses to Shaanxi Provincial Hospital of Traditional Chinese Medicine for 3 months in rotation to learn advanced nursing management methods and TCM nursing operation techniques.
(2) Nursing business learning requirements: the whole hospital organizes nursing lectures once every quarter, and all departments organize business learning once a month, with records and lecture notes.
(3) Nursing theory training content: nursing quality standards, various working systems, workflow, three basic nursing knowledge, specialist nursing routine, emergency plan, first aid knowledge, etc.
(4) Nursing skills training focus: standardized training of basic nursing operation and TCM nursing operation, especially for new employees and young nurses; Common first aid knowledge and skills.
(5) Actively participate in various short-term training courses organized by provincial and municipal nursing societies, constantly improve new knowledge, develop new business, and promote the improvement of nursing business level in the whole hospital.
(6) Invite nursing experts from outside the hospital to give special lectures on nursing business knowledge 1 ~ 2 times.
(7) Encourage nursing staff to continue their on-the-job study, improve their academic qualifications, knowledge level and intelligent structure of nursing team through self-study exams.
Five, actively participate in other activities of hospitals and social organizations.
extreme
First, the implementation of the Administration of Traditional Chinese Medicine "Chinese medicine hospital care guide", to further highlight the advantages and characteristics of traditional Chinese medicine in clinical nursing services.
1, combined with the actual situation in our hospital to further improve the system:
Traditional Chinese medicine nursing management system
Quality standard of traditional Chinese medicine nursing work
Chinese medicine nursing continuing education registration
Technical specification for nursing operation of traditional Chinese medicine
Clarify the responsibilities of nursing management departments and nursing managers, and standardize the professional behavior of nurses.
2. Improve the organization and management system of Chinese medicine.
Team leader of TCM nursing quality management:
Deputy team leader:
Team members:
Clear responsibilities, responsible for the implementation, inspection, evaluation and feedback of TCM nursing work in the whole hospital, reflecting the continuous improvement of TCM nursing work.
3, standardize the traditional Chinese medicine nursing routine:
In 20 1x, the nursing department organized the head nurses of all departments to revise and improve the routine nursing of traditional Chinese medicine in our hospital, and printed it into a book, requiring all departments to organize learning every month. The nursing group of traditional Chinese medicine goes to the department for random inspection from time to time, and those who fail to master or implement it are punished accordingly.
4, actively carry out traditional Chinese medicine nursing technology operation:
Each department shall carry out not less than two TCM nursing technology projects, and each department shall carry out two TCM nursing technologies for not less than 100 person-times per month, and must have a complete registration. The nursing department conducts random checks from time to time.
5. Actively carry out nursing with Chinese characteristics, provide patients with rehabilitation and health guidance with Chinese characteristics, and give full play to their unique advantages:
(1), each department formulates the contents of rehabilitation and health guidance suitable for common diseases, and organizes nurses to learn and implement them.
(2), to carry out different forms of vivid knowledge education and health publicity and education activities. Including promoting telephone return visits and providing nursing advice and guidance for discharged patients.
(3) Each department shall set up a publicity column for health education of common diseases to provide patients with easy-to-understand prescriptions for rehabilitation health education with Chinese medicine characteristics.
Second, take the patient as the center and improve the service consciousness of nurses.
1. Integrate the "patient-centered" nursing concept and humanistic care into the nursing service for patients, continuously improve and optimize various TCM nursing workflows, provide integrated and seamless nursing according to patients' needs while providing basic nursing services and professional technical services, and promote nursing work to be closer to patients, clinic and society.
2. Every month, according to the quantity and quality of clinical nursing work completed by nurses and patients' satisfaction, each department carries out the activity of evaluating excellence first, and selects a week every month to commend it, so as to further improve the service consciousness of nurses.
Third, strengthen management and promote the continuous improvement of clinical nursing quality.
1, flat nursing management. Nursing managers directly guide and serve clinical nursing work, shorten management radius and improve management efficiency. Nurses go to each ward at least twice a week to participate in nursing handover and administrative rounds, comprehensively evaluate the implementation of TCM nursing quality, handover system, doctor's advice check system, grading nursing system, nursing safety system and nursing workflow in each ward, and give feedback to the head nurse, and rectify the departments that are not implemented.
2. Further improve the technical files of nursing staff, establish and improve the nursing information system, and collect and analyze nursing-related information.
Four, to further implement the on-the-job education and training of Chinese medicine nurses.
1, nursing staff must receive continuing education of various nursing professions at all levels every year in accordance with the provisions of the Nurses Ordinance.
2, the nursing department to organize different levels of nursing staff "three basics" and traditional Chinese medicine specialist nursing knowledge and skills training.
3. Nursing departments and departments should establish the registration and assessment mechanism of continuing nursing education, record the learning and assessment results in detail, and keep them properly.
4. The nursing department should formulate the training plan of traditional Chinese medicine knowledge for nurses graduated from western medicine colleges, and accumulate 100 class hours within 3 years, and conduct assessment.
5. The nursing department should train and assess the basic theory of TCM, TCM nursing technology and TCM nursing knowledge at different levels every year, and keep the original records of assessment.
6, according to the undergraduate course room treated specialist diseases, formulate undergraduate nursing theory and technical training plan, regular assessment, keep the original record of assessment.
7, the nursing department should organize regular spot checks on nurses' nursing operation of traditional Chinese medicine, and put forward rectification opinions on the existing problems.
Fifth, highlight humanistic care and enhance the cohesion of nursing team.
1, people-oriented, pay attention to the ideological trends, physical and family conditions of nurses, and give limited help to nurses in need.
2.5. 12 International Nurses' Day (tentatively scheduled for May 6th) will hold a nursing etiquette activity with the theme of taking patients as the center, giving full play to the advantages of traditional Chinese medicine, and developing characteristic nursing of traditional Chinese medicine, so as to enliven the festive atmosphere and promote the further development of traditional Chinese medicine nursing.
Tisso
In 20 1x, the nursing work in our hospital still carried out the responsibility system of the director of nursing department under the leadership of the dean, and continued to establish the patient-centered service concept according to the standard requirements of the second-class first-class Chinese medicine hospital, focusing on medical safety, strengthening patient safety management and ensuring patient medical safety; Strengthen the training of nurses and improve the skill level of nurses at all levels; Actively carry out high-quality nursing service, strive to improve the quality of nursing service, improve the level of nursing technology and service quality, provide high-quality nursing service for patients and create a high-quality medical environment. The work plan is formulated as follows:
I. Work objectives
Around the hospital development goals, improve and implement various nursing management systems, fourteen nursing core systems, nursing operation procedures, nursing emergency plans and hospital infection management systems. Strictly abide by the relevant health policies and regulations and health administrative regulations of the Ministry of Health. Make all nursing work institutionalized, scientific, standardized and legalized.
Second, the specific measures
(1) Strengthen the management of nursing quality and safety, continuously improve the quality of nursing service and ensure nursing safety.
Nursing quality management is the eternal theme and the core content of nursing management. In the nursing work in 20 1x years, the nursing department will carefully assess, analyze, evaluate, rectify, track and re-evaluate according to various quality assessment standards and follow PDCA cycle mode, reflecting continuous improvement and implementing target management.
1, the nursing quality control team in the hospital supervises the nursing quality of each nursing unit every month, corrects the existing problems in time, and organizes the nursing quality and nursing care once a month.
Hold a good event analysis meeting to promote the continuous improvement of nursing quality.
2. Strengthen the nursing quality management of key links, key time periods, key people and key departments (disinfection supply room, operating room, emergency department and hemodialysis room), and the nursing department will supervise the departments irregularly according to the requirements of dimethyl standard to ensure nursing safety.
3. Further strengthen the management and control of hospital infection, strictly abide by the disinfection and isolation system, strengthen occupational protection, ensure the safety of nursing staff, and do a good job in the management, use and treatment of disposable articles and medical wastes.
4. Improve the patient risk assessment system; Strengthen the management of critically ill patients and nursing adverse events, timely check the high-risk patients and adverse events reported by wards, and put forward reasonable suggestions to avoid medical disputes.
5. Make emergency plans during holidays.
(2) Strengthen the connotation of high-quality nursing and implement holistic nursing responsibility system.
1, strengthen nursing human resource management, implement nurse post management, and meet clinical nursing needs as much as possible.
2. Implement the patient-centered service concept, implement the holistic nursing responsibility system according to the grading nursing and specialist nursing standards, strengthen health education, and provide safe, high-quality, efficient and satisfactory services for patients and their families.
3. Further strengthen the assessment of high-quality nursing service, hold special meetings of head nurses regularly, and constantly summarize and improve clinical nursing work.
4. The nursing department conducts a monthly survey on patients' satisfaction, widely listens to the opinions of patients and their families, and constantly improves the service attitude and quality.
(3) The whole hospital ward implements the TCM nursing plan and standardizes the TCM nursing operation of nursing staff.
Technology.
(D) to speed up the training of head nurses and nurses' working ability, and effectively improve the overall quality of the nursing team.
1. Strengthen the work assessment of head nurses, and conduct a theoretical assessment for head nurses under 40 every quarter.
2. The nursing department regularly organizes business study in the whole hospital, and the department organizes business study once a month. The hospital conducts theoretical assessment once every quarter, technical operation assessment once, and the department conducts operational and theoretical assessment once a month.
3. Strengthen the training and assessment of nursing core system, responsibilities, processes and emergency plans.
5. The nursing department regularly and irregularly organizes nursing rounds, teaching rounds, nursing consultation and difficult case discussion, and the department organizes 1 nursing rounds every month.
6. Strengthen the training of specialized nurses, arrange to go out for further study, and accelerate the construction and development of specialized nursing.
7. Encourage nurses and head nurses to participate in various forms of learning, and improve their academic level and management level. This year, it is planned to send some young head nurses and business backbones out for further study.
(5) Carry out scientific research with innovative thinking to promote clinical nursing teaching.
1. Strengthen the study of new theories, new knowledge and new technologies of nurses, constantly broaden their horizons, innovate their thinking, carry out nursing research and actively write nursing papers.
2. Actively carry out clinical nursing teaching. Strengthen the management of practice, advanced study and new nurses. Interns can enter the clinic only after pre-job education and pre-job training. They can hold symposiums regularly to summarize the practice teaching work, and conduct theoretical and operational assessment before leaving the department. New nurses can take up their posts only after passing the pre-job training.
(6) Cooperate with hospitals to implement tobacco control and create smoke-free hospitals.
(7) Cooperate with the hospital trade union and the * * * Youth League Committee to carry out some meaningful recreational activities, enrich their spare time and improve the cohesion and centripetal force of the nursing team.
(eight) to strengthen supervision, implementation and inspection, to ensure that the comprehensive evaluation of nursing quality is up to standard. Each nursing quality control team has a clear division of labor, and goes deep into the department for inspection in strict accordance with various quality assessment standards. The nursing department pays special attention to supervision from time to time, makes records, analyzes and evaluates, and formulates corrective measures to make all assessment items meet the standards. The standard is as follows (total score 100):
1, qualified rate of basic nursing ≧90%
2, specialist nursing qualified rate ≧95%
3, grading nursing qualified rate ≧95%
4, critically ill patients nursing qualified rate ≧90%
5. The intact rate of first-aid articles 100%.
6. The qualified rate of disinfection and sterilization of conventional instruments is 100%.
7, nursing documents written qualified rate ≧95%
8, patients' satisfaction with nursing work ≧95%
9, nursing technology operation qualified rate ≧90%
10, and the qualified rate is ≧90%.
1 1, and the incidence of pressure ulcers was 0.
13, qualified rate of medical waste treatment 100%
1x, one person, one needle, one tube for one use, and the sterilization qualified rate reached 100%.
After 1x, the disfigurement rate of disposable syringes and transfusion devices reached 100%.
16, and the health education coverage rate reached 100%.
17, the success rate of health education ≧90%
18, coverage rate of quality nursing service 100%
19, the overall nursing qualification rate of responsibility system ≧90%